Bruce Cain argues that "both parties agree that the country has serious infrastructure needs—but even with a new proposal on the table, we may end up with next to nothing." Cain explains that while permitting large infrastructure projects is a complex, time-consuming, and, at times, confusing process, America's infrastructure needs will soon need to be addressed by both parties. Read more here. 

Jeremy Weinstein writes about the Trump administration's response to the ongoing refugee crisis in Foreign Policy Magazine. Weinstein explains that, for the current administration to "back up its commitment to innovation and efficiency," it could start with "A modern system of matching refugees to the communities where they are most likely to succeed could reduce costs and improve outcomes, forming a critical element of a global reform agenda for refugee resettlement." Read the full story here.

"There is growing consensus that populism constitutes a grave threat to liberal democracy, and to the liberal international order on which peace and prosperity have rested for the past two generations," writes Francis Fukuyama in the World Economic Forum. The fate of the global liberal order could be jeopardized due to rising populist powers and movements. Read the full article here. 

Screening all adults for hepatitis C virus infection (HCV) is a cost-effective way to improve clinical outcomes of HCV and identify more infected people compared to current recommendations, according to a new study by SHP’s Joshua Salomon and colleagues.

Using a simulation model, Salomon, a professor of medicine and core faculty member at Stanford Health Policy, and researchers from Boston Medical Center (BMC) and Massachusetts General Hospital (MGH) found that this expanded screening would increase life expectancy and quality of life while remaining cost-effective.

The infectious disease primarily attacks the liver. It is believed that one-in-30 Baby Boomers — born between 1945 and 1965 — have HCV, but don’t even know it because it can take years before symptoms emerge. The Centers for Disease Control and Prevention currently recommends HCV testing for boomers, but testing rates in this group remain relatively low, and recent trends show a higher incidence rate of HCV among young people.

“Testing all adults would lead to earlier diagnosis and treatment for many people, which would help to prevent cirrhosis and other long-term complications,” says Salomon, co-senior author of the study published in Clinical Infectious Diseases. “Overall, when you consider both the better health outcomes and the reduced costs of managing long-term liver disease, expanded testing offers excellent value for money.”

To address the potential benefits of changing the testing recommendations, the researchers created simulations to estimate the effectiveness of HCV testing strategies among different age groups. They compared effects of the current testing recommendations; of testing people over 40 years old or over 30 years old, and of testing all adults over 18 years old. All strategies included the current recommendations for targeted testing of high-risk individuals, such as people who inject drugs.

The study found that screening all adults would identify more than 250,000 additional people with HCV, increase cure rates from 41 to 61 percent, and reduce death rates for HCV-attributable diseases more than 20 percent, compared with current recommendations.

“When we expanded testing, the results were compelling,” says Joshua Barocas, lead author on the study and an infectious disease physician at MGH and an instructor in medicine at Harvard Medical School. “Changing the current recommendations could have a major public health impact, improving the quality of life for young people with HCV, and reducing death rates.”

The research team used data from national databases, clinical trials, and observational cohorts to inform their simulation models, which captured the details and dynamics of U.S. population demographics and HCV epidemiology.

All of the age-based strategies decreased costs related to managing chronic HCV and advanced liver disease, but the strategy of testing all adults was most effective. Even in a simulated scenario that required twice as much testing among uninfected people to identify the same number of HCV cases, the testing-all-adults strategy remained cost-effective.

Researchers say these findings should be considered by the CDC for future recommendations on HCV testing.

“Due in part to the opioid epidemic and the increase in injection drug use, the country has seen an increase in cases of HCV among young people,” says Benjamin Linas, MD, co-senior author of the study and infectious disease physician at BMC and an associate professor of medicine at Boston University Medical Center. “The CDC could address this public health concern by recommending all adults receive a one-time HCV test.”

The study was published online in Clinical Infectious Diseases and was funded by the National Institute on Drug Abuse at the National Institutes of Health, the MGH Fund of Medical Delivery and the U.S. Centers for Disease Control and Prevention.

As global health assistance for developing countries dwindles, a Stanford student working on her PhD in health policy has developed a novel formula to help donors make more informed decisions about where their dollars should go.

Donors have typically relied predominately on gross national income (GNI) per capita to determine aid allocations. But using GNI is problematic because it effectively penalizes economic growth. It also fails to capture contextual nuances important to channeling aid effectively and efficiently.

So Tara Templin, a first-year Stanford PhD student specializing in health economics, and her Harvard colleague Annie Haakenstad, have developed a framework that estimates funding based on needed resources, expected spending and potential spending into 2030. They believe the more flexible model makes it adaptable for use by governments, donors and policymakers.

“We've observed development assistance for health growth attenuate over the last seven years,” said Templin, who was a research fellow at the Institute for Health Metrics and Evaluation before coming to Stanford. “There are difficult trade-offs, and this entails honing in on the specific challenges and countries most in need.”

Their research published in the journal Health Policy and Planning outlines how their “financing gaps framework” can be adapted to short- or long-run time frames, between or within countries.

“Depending on donor preferences, the framework can be deployed to incentivize local investments in health, ensuring the long-term sustainability of health systems in low- and middle-income countries, while also furnishing international support for progress toward global health goals,” write the authors, who also are Stephen Lim of the University of Washington, Jesse B. Bump of Harvard and Joseph Dieleman, also at the University of Washington.

The authors developed a case study of child health to test out their framework. It shows that priorities vary substantially when using their results as compared to focusing mainly on GNI per capita or child mortality.

The case study uses data from the Global Burden of Disease 2013 Study, Financing Global Health 2015, the WHO Global Health Observatory and National Health Accounts. Funding flows are anchored to progress toward the U.N. Sustainable Development Goals’ target for reductions in the death rates of children under 5. More than six million children die each year before their fifth birthday, so the United Nations set a goal to reduce under-5 mortality to at least 25 per 1,000 live births.

To build their child health case study, the authors relied on a 2015 study that estimated the average cost per child-life saved is $4,205 in low-income countries, $6,496 in lower-middle income countries and $10,016 in upper-middle countries.

The framework considers three concepts. First, expected government spending is constructed from national health accounts, which are standardized financial reports from countries around the world. Second, ability to pay is estimated by looking at countries with similar levels of economic development and looking at associations with country investment in the health sector. Lastly, needed investment considers a health target, the country’s current health burden, and average costs to save children’s lives in each country.

“Our focus is on the gap between the resources needed to reach critical health targets and domestic health spending,” the authors wrote. “We highlight two facets of domestic health resources—expected spending and potential spending—as critical. While donor preferences may vary, basing aid allocation on expected or existing spending levels incentivizes countries to spend less on health. We therefore propose the use of potential spending, which is a measure of a country’s ability to pay, as the domestic resource benchmark.”

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Instead of the gap between expected spending and need, their framework focuses on the gap between potential spending and the health resources needed to meet global health targets. In the framework, policymakers can choose which gap they want to target, since this decision can involve many factors.

“By focusing on that gap, donors can catalyze sustained domestic spending while also addressing the resource needs critical to reaching international health goals,” they wrote.

They then looked at 10 countries with the most need for additional child health resources. The gap between expected spending and potential spending was highest in Afghanistan, at 79 percent, and lowest in Cameroon, where expected spending exceeded potential spending.

“Fifty years ago, GNI was the best proxy for countries’ ability to finance their own development and health,” the authors wrote.

But today, more empirical data and technology are available, allowing donors to incorporate a broader set of health financing measures into their decision-making process.

“The flexible but targeted nature of our framework is critical in the current era of global health financing,” said Haakenstad, the lead author. “Our framework helps to ensure the poor and disadvantaged, the majority of which now reside in middle-income countries, are reached by development assistance and other public financing. This funding is critical to reducing death and disability and reaching global targets in health.”

The authors’ research was supported by the Welcome Trust (099114/Z/12/Z).